Body dysmorphic disorder

Body dysmorphic disorder (BDD), also termed body dysmorphia or dysmorphic syndrome, but originally termed dysmorphophobia, is a mental disorder characterized by an obsessive preoccupation that some aspect of one's own appearance is severely flawed and warrants exceptional measures to hide or fix it.^[1] In BDD's delusional variant, the flaw is imagined.^[2] If the flaw is actual, its importance is severely exaggerated.^[2] Either way, one's thoughts about it are pervasive and intrusive, occupying up to several hours a day. The DSM-5 categorizes BDD in the obsessive–compulsive spectrum, and distinguishes it from anorexia nervosa.

A fairly common mental disorder, affecting some 1.7% to 2.4% of the population, BDD usually starts during adolescence, and affects men and women roughly equally.^[2] (The BDD subtype muscle dysmorphia, perceiving the body as too small, affects mostly males.)^[3] Besides thinking about it, one repetitively checks and compares the perceived flaw, and can adopt unusual routines to avoid social contact that exposes it.^[2] Fearing the stigma of vanity, one usually hides the preoccupation.^[2] Commonly unsuspected even by psychiatrists, BDD has been greatly underdiagnosed.^[2] Severely impairing quality of life via educational and occupational dysfunction and social isolation, BDD involves especially high rates of suicide and suicidal ideation.^[2]

History

In 1886, Enrico Morselli reported a disorder that he termed dysmorphophobia.^[4] In 1980, the American Psychiatric Association recognized the disorder in the third edition of its DSM—the Diagnostic and Statistical Manual of Mental Disorders—while identifying it as a somatoform disorder. The manual's 1987 revision switched the term to body dysmorphic disorder. Published in 1994, DSMs fourth edition defines BDD as a preoccupation with an imagined or trivial defect in appearance, a preoccupation causing clinically significant distress or dysfunction—socially, occupationally, or educationally—and not better explained as another disorder, such as anorexia nervosa.^[5] Published in 2013, the DSM-5 shifts BDD to a new category, obsessive–compulsive spectrum, adds operational criteria, such as repetitive behaviors or mental acts, and notes the subtype muscle dysmorphia: perceiving one's body as too small or insufficiently muscular or lean.

Symptoms

Whereas vanity concerns preoccupation with aggrandizing the appearance, BDD is compulsion to merely normalize the appearance.^[2] BDD shares features with obsessive-compulsive disorder (OCD),^[6] but involves more depression and social avoidance.^[1] BDD often associates with social anxiety disorder.^[7]

In BDD, the perceived bodily defect can be at virtually any area, yet is usually the nose, skin, or hair.^[2] Attempts at self-treatment can paradoxically create lesions where none previously existed.^[2] BDD often drives a quest to obtain dermatological treatment or cosmetic surgery, which interventions typically do not resolve the distress.^[2] Sometimes deluded in believing that persons are covertly pointing out their flaws, some persons experiencing BDD can react violently to perceived putdowns.^[2]

Most generally, one experiencing BDD ruminates over the perceived bodily defect up to several hours daily, uses either social avoidance or camouflaging with cosmestics or apparel, repetitively checks the appearance, compares it to that of other persons, and might often seek verbal reassurances.^[1][2] BDD's severity can wax and wane, and flareups tend to yield absences from school, work, or socializing, sometimes leading to protracted social isolation, with some becoming housebound for extended periods.^[2] The distress of BDD tends to exceed that of either major depressive disorder or type-2 diabetes, and rates of suicidal ideation and attempts are especially high.^[2]

Causation

As with most mental disorders, BDD's causation is likely intricate, altogether biopsychosocial, through an interaction of multiple factors, including genetic, developmental, psychological, social, and cultural.^[8][9] Though twin studies into BDD are few, one estimated its heritability at 43%, and its heritability overlaps with obsessive-compulsive disorder (OCD).^[10] Others such as Jay Joseph dispute the rates of heritability in mental illness.

Additional factors that can influence BDD include introversion,^[11] perfectionism, negative body image,^[8][12] childhood abuse and neglect,^[9][13] and heightened aesthetic sensitivity.^[9]

Diagnosis

Estimates of prevalence and gender distribution have varied widely via discrepancies in diagnosis and reporting.^[1] In American psychiatry, BDD gained diagnostic criteria in the DSM-IV, but clinicians' knowledge of it, especially among general practitioners, is constricted.^[14] Meanwhile, the shame that persons feel about having the bodily concern, and fearing the stigma of vanity, hinders recognition.^[2][15] BDD is sometimes mistaken for major depressive disorder or social phobia.^[16] BDD is severely under-diagnosed even in psychiatric patients.^[17] Correct diagnosis calls for specialized questioning and correlation with emotional distress or social dysfunction.^[17] Estimates place the Body Dysmorphic Disorder Questionnaire's specificity at 92.5% and its sensitivity at 100%.^[18]

Treatment

BDD's delusional variant does not respond to treatment with antipsychotic drugs, but instead with some antidepressant drugs: the selective serotonin reuptake inhibitors (SSRIs).^[2] The gold-standard psychological intervention for BDD is cognitive-behavioral therapy (CBT).^{[19][20][21][22]} The main techniques in CBT for BDD are exposure and response prevention. Exposure means helping the patient confront situations that provoke irrational fear (such as going out in public with the perceived physical defect exposed); response prevention means resisting urges to ask for reassurance, use excessive makeup to conceal the perceived defect, or repeatedly check one's appearance in the mirror.

Neurobiology

Neuroimaging^[23] suggest weaker connection between the amygdala (involved in basic emotions) and the orbitofrontal cortex (involved in regulation of emotional arousal).^[24] Cognitive-behavioral therapy may improve connections between the orbitofrontal cortex and the amygdala.^[24]

Notes

External links

• Looks that Kill, TV documentary by a recovered person with BDD, John Furse
• International Obsessive Compulsive Disorder Foundation BDD website